International consensus on the most useful assessments used by physical therapists to evaluate patients with temporomandibular disorders: A Delphi study.

OBJECTIVE: To identify assessment tools used to evaluate patients with temporomandibular disorders (TMD) considered to be clinically most useful by a panel of international experts in TMD physical therapy (PT). METHODS: A Delphi survey method administered to a panel of international experts in TMD PT was conducted over three rounds from October 2017 to June 2018. The initial contact was made by email. Participation was voluntary. An e-survey, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was posted using SurveyMonkey for each round. Percentages of responses were analysed for each question from each round of the Delphi survey administrations. RESULTS: Twenty-three experts (completion rate: 23/25) completed all three rounds of the survey for three clinical test categories: 1) questionnaires, 2) pain screening tools and 3) physical examination tests. The following was the consensus-based decision regarding the identification of the clinically most useful assessments. (1) Four of 9 questionnaires were identified: Jaw Functional Limitation (JFL-8), Mandibular Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD) and the neck disability index (NDI). (2) Three of 8 identified pain screening tests: visual analog scale (VAS), numeric pain rating scale (NRS) and pain during mandibular movements. (3) Eight of 18 identified physical examination tests: physiological temporomandibular joint (TMJ) movements, trigger point (TrP) palpation of the masticatory muscles, TrP palpation away from the masticatory system, accessory movements, articular palpation, noise detection during movement, manual screening of the cervical spine and the Neck Flexor Muscle Endurance Test. CONCLUSION: After three rounds in this Delphi survey, the results of the most used assessment tools by TMD PT experts were established. They proved to be founded on test construct, test psychometric properties (reliability/validity) and expert preference for test clusters. A concordance with the screening tools of the diagnostic criteria of TMD consortium was noted. Findings may be used to guide policymaking purposes and future diagnostic research.

The Diagnostic Validity of Clinical Tests in Temporomandibular Internal Derangement: A Systematic Review and Meta-analysis.

PURPOSE: To assess the diagnostic validity of clinical tests for temporomandibular internal derangement relative to magnetic resonance imaging (MRI). METHODS: MEDLINE and Embase were searched from 1994 through 2009. Independent reviewers conducted study selection; risk of bias was assessed using Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews (QUADAS); ≥9/14) and data abstraction. Overall quality of evidence was profiled using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Agreement was measured using quadratic weighted kappa (κw). Positive (+) or negative (-) likelihood ratios (LR) with 95% CIs were calculated and pooled using the DerSimonian-Laird method and a random-effects model when homogeneous (I(2)≥0.40, Q-test p≤0.10). RESULTS: We selected 8 of 36 studies identified. There is very low quality evidence that deflection (+LR: 6.37 [95% CI, 2.13-19.03]) and crepitation (LR:5.88 [95% CI, 1.95-17.76]) as single tests and crepitation, deflection, pain, and limited mouth opening as a cluster of tests are the most valuable for ruling in internal derangement without reduction (+LR:6.37 [95% CI, 2.13-19.03]), (-LR:0.27 [95% CI, 0.11-0.64]) while the test cluster click, deviation, and pain rules out internal derangement with reduction (-LR: 0.09 [95% CI, 0.01-0.72]). No single test or cluster of tests was conclusive and of significant value for ruling in internal derangement with reduction. CONCLUSIONS: Findings of this review will assist clinicians in deciding which diagnostic tests to use when internal derangement is suspected. The literature search revealed a lack of high-quality studies; further research with adequate description of patient populations, blinded assessments, and both sagittal and coronal MRI planes is therefore recommended.Purpose: To assess the diagnostic validity of clinical tests for temporomandibular internal derangement relative to magnetic resonance imaging (MRI). Methods: MEDLINE and Embase were searched from 1994 through 2009. Independent reviewers conducted study selection; risk of bias was assessed using Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews (QUADAS); ≥9/14) and data abstraction. Overall quality of evidence was profiled using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Agreement was measured using quadratic weighted kappa (κw). Positive (+) or negative (−) likelihood ratios (LR) with 95% CIs were calculated and pooled using the DerSimonian­Laird method and a random-effects model when homogeneous (I2≥0.40, Q-test p≤0.10). Results: We selected 8 of 36 studies identified. There is very low quality evidence that deflection (+LR: 6.37 [95% CI, 2.13­19.03]) and crepitation (LR:5.88 [95% CI, 1.95­17.76]) as single tests and crepitation, deflection, pain, and limited mouth opening as a cluster of tests are the most valuable for ruling in internal derangement without reduction (+LR:6.37 [95% CI, 2.13­19.03]), (−LR:0.27 [95% CI, 0.11­0.64]) while the test cluster click, deviation, and pain rules out internal derangement with reduction (−LR: 0.09 [95% CI, 0.01­0.72]). No single test or cluster of tests was conclusive and of significant value for ruling in internal derangement with reduction. Conclusions: Findings of this review will assist clinicians in deciding which diagnostic tests to use when internal derangement is suspected. The literature search revealed a lack of high-quality studies; further research with adequate description of patient populations, blinded assessments, and both sagittal and coronal MRI planes is therefore recommended.

RÉSUMÉ Objectif : Évaluer la validité du diagnostic résultant de tests cliniques en imagerie de résonance magnétique (IRM) pour le dépistage du dérangement interne de l'articulation temporo-mandibulaire (ATM). Méthode : Une recherche a été effectuée dans les bases de données MEDLINE et Embase pour les années 1994 à 2009. Des examinateurs indépendants ont procédé au choix des études répertoriées ; les risques de biais ont été évalués à l'aide de l'échelle QUADAS (Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews), visant à évaluer la qualité des études sur la fiabilité diagnostique incluses dans les revues systématiques (le pointage obtenu a été ≥9/14) et à l'aide d'abstraction des données. Le profil de la qualité globale des preuves a été établi avec l'échelle GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Le degré d'accord a été mesuré à l'aide du coefficient quadratique kappa pondéré (κw). Les rapports de vraisemblance (RV) positifs (+) ou négatifs (−) avec intervalles de confiance de 95 % ont été calculés et groupés suivant la méthode de DerSimonian­Laird et à l'aide d'un modèle à effets aléatoires lorsque les données étaient homogènes (I2≥0,40, test-Q p≤0,10). Résultats : Nous avons retenu 8 des 36 études identifiées. Les preuves voulant que les tests individuels de déviation (RV+ : 6,37 [95 % IC : 2,13­19,03]) et de crépitation ([RV : 5,88 [95 % IC : 1.95­17.76]) soient fiables étaient de très faible qualité, alors qu'un ensemble de tests regroupant crépitation, déviation, douleur et ouverture limitée de la bouche sont les plus valables au moment de déterminer s'il y a effectivement dérangement interne sans réduction (RV+ : 6,37 [95 % IC : 2,13­19,03]), (RV− : 0,27 (95 % IC : 0,11­0,64]), alors que les tests regroupés ­ claquement, déviation et douleur ­ déterminent habituellement s'il y a dérangement interne avec réduction (RV− : 0,09 [95 % IC : 0,01­0,72]). Aucun test unique ni aucun groupe de tests ne semblent avoir de valeur considérable ou significative ni concluante pour déterminer avec précision un dérangement interne avec réduction. Conclusions : Les conclusions de cet examen aideront les cliniciens à décider quels tests diagnostics utiliser lorsqu'ils soupçonnent un dérangement interne. La recherche documentaire a révélé un manque d'études de grande qualité ; des recherches supplémentaires comportant une description adéquate des populations de patients, des évaluations à l'aveugle et des plans sagittaux et coronaires de l'IRM sont donc recommandés.